Broward College - Peer Mentoring Program

In order to pair/match you with your future mentees, please complete this survey for this
service year. Our program staff uses various common points for matching, primarily education pathways.

All Peer Leaders must complete this survey every new year of service.

Mentor Application Form

First Name *

Last Name *

BC Staff email (NOT your student email. Example: username@broward.edu) *

No Email

BC Zoom Phone Number * phone: url_zoom:

Major (Specify) *

Pronouns

If other:

Select Your Primary Educational Pathway: *

If other, please specify:

Campus *

If other:

If other, please specify:

Please specify your career goals or ideal job: *

Age:

I am proficient in the following languages:

Portuguese Spanish French Creole

If other, please specify:

Sex: *

Ethnicity

If other, please specify:

How many mentees can you help at a time? *

_{at least:
- 8 characters
- one upper case character
- one lower case character
- one number
- one special character (such as $!*)} Please create a password

Confirm that password
Show Password

Mentor Consent

I agree to the Mentoring Agreement *

I agree to the Privacy Policy *

I agree to the Code of Conduct *

Become a Mentor

Mentor Application Form

Mentor Consent